Provider Demographics
NPI:1760641757
Name:IVY LEAGUE HEALTH & FITNESS
Entity Type:Organization
Organization Name:IVY LEAGUE HEALTH & FITNESS
Other - Org Name:SOURCE INSTITUTE FOR HUMAN PERFORMANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF TRAINING
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:NOGAKI
Authorized Official - Suffix:
Authorized Official - Credentials:CSCS
Authorized Official - Phone:609-925-1159
Mailing Address - Street 1:66 WITHERSPOON ST
Mailing Address - Street 2:PMB 403
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08542-3226
Mailing Address - Country:US
Mailing Address - Phone:609-925-1159
Mailing Address - Fax:609-925-1159
Practice Address - Street 1:66 WITHERSPOON ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08542-3239
Practice Address - Country:US
Practice Address - Phone:609-925-1159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2011-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty